A Baby-Led Approach to Eating Solids and Risk of Choking

Discussion

The BLISS approach to complementary feeding, which included specific advice to minimize the risk of food-related choking, did not appear to result in more choking events in the first year of life than were observed in the control group. However, half of all infants were offered ≥1 food posing a choking risk during 3 days of diet recording at 7 months of age, which increased to nearly all infants at 12 months. Of the 129 parent-defined most serious choking episodes reported, only 23% of the foods involved were items from a list of foods considered to pose a choking risk. The majority of events occurred when the infants were feeding themselves whole foods, regardless of study group. Gagging was reasonably common, with BLISS infants gagging more often than control infants at 6 months of age but less often at 8 months of age, presumably as they became more experienced at feeding themselves.

It is difficult to compare our findings because there have been so few studies. It is also important to note that our intervention used a modified version of BLW. The modified version strongly encouraged delaying complementary feeding until 6 months of age and provided written and verbal messages specifically designed to reduce food-related choking. Our observation that BLISS did not increase the risk of choking relative to more traditional feeding methods should not be extrapolated to unmodified versions of BLW. The only existing data on choking in BLW come from our BLISS research group, a small survey reporting similar “ever” choking rates of 31% to 40% in BLW infants and 31% in conventionally fed infants.¹²

There are a number of possible explanations for infants so frequently being offered foods that pose a choking risk. Parents receive a wealth of information in the first year of their child’s life,¹⁵ and it is possible that messages about food-related choking are overshadowed by other topics such as breastfeeding and safe sleeping practices or that the information is not easily applied. Advice on modifying foods that pose a choking risk may be beneficial, especially where healthful foods (eg, raw vegetables) are involved, because parents may not want to limit these foods in their infant’s diet or in shared meals. Advice to avoid raw apple may be particularly important because previous BLW research indicated it was the food most commonly associated with choking.⁸ Our diet record data are reassuring in that this advice was generally adhered to in BLISS, with only 1 infant offered raw apple at 7 months of age, compared with 11 control infants.

Our finding that only 23% of the foods responsible for the 129 food-related choking episodes described by parents were items from our list of foods posing a choking risk may lead to questions about the comprehensiveness of the list. However, it was based on material from a range of literature, with additional development by experienced pediatric speech–language therapists. Rather, our findings indicate that infants can choke on a wide variety of foods and liquids, so it will not be possible to prevent all food-related choking, regardless of feeding method. Our results also suggest that the severity, and therefore clinical importance, of the choking events reported varied. For example, it is likely that the 51 episodes resolved by the infant alone have limited clinical importance compared with the 3 choking episodes where health professionals became involved. Two of these 3 events were unrelated to the intervention because they were hospital admissions resulting from choking on milk rather than solid foods. The third event involved a BLISS parent placing a piece of food directly in the infant’s mouth, which contradicted BLISS guidelines (Fig 1). It is therefore important that parents who follow baby-led approaches are given, understand, and implement safety advice (eg, Fig 1). Furthermore, close supervision of all infant eating occasions (regardless of the method of infant feeding) is of paramount importance so that any unavoidable episodes of choking can be identified and managed promptly.^1,23,24 The majority of choking episodes occurred during infant self-feeding of whole foods, although there was no evidence that following a baby-led approach increased the risk of choking itself. However, it is important to remember that the majority of infants who adhered to a baby-led approach were in the BLISS group and so had received specific advice to decrease their risk of choking.

The BLISS study is the first randomized controlled trial to investigate the safety of a baby-led approach to infant feeding. Strengths include the use of multiple methods of measurement and repeated careful assessment. However, there were also some limitations. It is possible that some misclassifications of choking episodes occurred because they were parent-defined. However, considerable efforts were made to ensure that parents clearly understood the differences between gagging and choking, and 117 (92%) of the 127 episodes of choking directly observed by a parent included ≥1 indication of airway compromise (“coughed,” “gasped,” or “went silent”), suggesting that overall misclassification was low. Although recall bias was possible in the retrospective questionnaires, comparable data were collected from the daily calendars, suggesting that recall of choking and gagging was accurate (Table 2). Because the study was powered to detect differences in infant BMI rather than choking, we had insufficient power to determine whether the rates of the most clinically significant choking events (necessitating medical intervention) differed by group. We also recognize that the response rate to the study was low (23% of eligible Dunedin births), and the sample was socioeconomically advantaged, which may limit extrapolation to other populations.